FMLA Certification of Health Care Provider ... - San Angelo ISD

CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
FAMILY AND MEDICAL LEAVE ACT
Section I: For Completion by the EMPLOYER
Form WH-380-E
San Angelo ISD Revised December 2009
INSTRUCTIONS to the EMPLOYER: The Family and Medical Leave Act (FMLA) provides that an employer may require an employee seeking
FMLA protections because of a need for leave due to a serious health condition to submit a medical certification issued by the employee’s health care
provider. Please complete Section I before giving this form to your employee. Your response is voluntary. While you are not required to use this form,
you may not ask the employee to provide more information than allowed under the FMLA regulations, 29 C.F.R. §§ 825.306–825.308. Employers
must generally maintain records and documents relating to medication certifications, re-certifications, or medical histories of employees created for
FMLA purposes as confidential medical records in separate files/records from the usual personnel files and in accordance with 29 C.F.R. § 1630.14
(c) (1), if the Americans with Disabilities Act applies.
Employer Name and Contact: San Angelo Independent School District
1621 University Avenue
San Angelo, TX 76904
Employee’s Job Title:
Regular Work Schedule: ________________
Employee’s Essential Job Functions: ________________________________________________________________
_____________________________________________________________________________________________
Job description attached
Section II: For Completion by the EMPLOYEE
INSTRUCTIONS to the EMPLOYEE: Please complete Section II before giving this form to your medical provider. The FMLA permits an
employer to require that you submit a timely, complete, and sufficient medical certification to support a request for FMLA leave due to your own
serious health condition. If requested by your employer, your response is required to obtain or retain the benefit of FMLA protections, 29 U.S.C. §§
2613, 2614 (c)(3). Failure to provide a complete and sufficient medical certification may result in a denial of your FMLA request, 29 C.F.R. §
825.313. Your employer must give you at least 15 calendar days to return this form, 29 C.F.R. §825.305(b).
Name: ________________________________________________________________________________________
First Middle Last
Section III: For Completion by the HEALTH CARE PROVIDER
INSTRUCTIONS to the HEALTH CARE PROVIDER: Your patient has requested leave under the FMLA. Answer, fully and completely, all
applicable parts. Several questions seek a response as to frequency or duration of a condition, treatment, etc. Your answer should be your best
estimate based upon your medical knowledge, experience, and examination of the patient. Be as specific as you can; terms such as “lifetime,”
“unknown,” or “indeterminate” may not be sufficient to determine FMLA coverage. Limit your responses to the condition for which the employee is
seeking leave. Please sign the form on the last page.
Provider’s Name and Business Address: _____________________________________________________________
_____________________________________________________________________________________________
Type of Practice / Medical Specialty: _______________________________________________________________
Telephone: ( ) Fax: ( )
Part A: Medical Facts
1. Approximate date condition commenced: __________________________________________________________
Probable duration of condition: _________________________________________________________________
Mark below as applicable:
Was the patient admitted for an overnight stay in a hospital, hospice, or residential medical care facility?
Yes No
If yes, provide dates of admission: ________________________________________________
Date(s) you treated the patient for condition: ______________________________________________________
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CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
FAMILY AND MEDICAL LEAVE ACT
Will the patient need to have treatment visits at least twice per year due to the condition? Yes No
Was medication, other than over-the-counter medication, prescribed? Yes No
Was the patient referred to other health care provider(s) for evaluation or treatment (e.g., physical therapist)?
Yes No If yes, state the nature of such treatments and expected durations of treatment:
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Is the medical condition pregnancy? Yes No If yes, expected delivery date:
3. Use the information provided by the employer in Section I to answer this question. If the employer fails to provide
a list of the employee’s essential functions or a job description, answer these questions based upon the employee’s
own description of his/her job functions.
Is the employee unable to perform any of his/her job functions due to the condition? Yes No
If so, identify the job functions the employee is unable to perform: _____________________________________
__________________________________________________________________________________________
4. Describe other relevant medical facts, if any, related to the condition for which the employee seeks leave (such
medical facts may include symptoms, diagnosis, or any regimen of continuing treatment such as the use of
specialized equipment):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Part B: Amount of Leave Needed
5. Will the employee be incapacitated for a single continuous period of time due to his/her medical condition,
including any time for treatment and recovery? Yes No If so, estimate the beginning and ending dates
for the period of incapacity:
__________________________________
6. Will the employee need to attend follow-up treatment appointments or work part-time or on a reduced schedule
because of the employee’s medical condition? Yes No
If so, are the treatments or the reduced number of hours of work medically necessary? Yes No
Estimate treatment schedule, if any, including the dates of any scheduled appointments and the time required for
each appointment, including any recovery period: __________________________________________________
__________________________________________________________________________________________
Estimate the part-time or reduced work schedule the employee needs, if any:
hour(s) per day; days per week from through _____________
7. Will the condition cause episodic flare-ups periodically preventing the employee from performing his/her job
functions? Yes No
Is it medically necessary for the employee to be absent from work during the flare-ups? Yes No
If yes, explain: ______________________________________________________________________________
__________________________________________________________________________________________
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CERTIFICATION OF HEALTH CARE PROVIDER FOR EMPLOYEE’S SERIOUS HEALTH CONDITION
FAMILY AND MEDICAL LEAVE ACT
Based upon the patient’s medical history and your knowledge of the medical condition, estimate the frequency of
flare-ups and the duration of related incapacity that the patient may have over the next 6 months (e.g., 1 episode
every 3 months lasting 1–2 days).
Frequency: times per week(s) month(s)
Duration: hours or day(s) per episode
Additional Information: Identify Question Number with Your Additional Answer
Signature of Health Care Provider
Date
PAPERWORK REDUCTION ACT NOTICE AND PUBLIC BURDEN STATEMENT
If submitted, it is mandatory for employers to retain a copy of this disclosure in their records for three years, 29 U.S.C. § 2616, 29 C.F.R. §
825.500. Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. The
Department of Labor estimates that it will take an average of 20 minutes for respondents to complete this collection of information, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, send them to the Administrator, Wage and Hour Division, U.S. Department of Labor, Room S-
3502, 200 Constitution Ave., NW Washington, DC 20210. DO NOT SEND COMPLETED FORM TO THE DEPARTMENT OF LABOR;
RETURN TO THE PATIENT.
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